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Job Requirements of Appeals Specialist I:
-
Employment Type:
Contractor
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Location:
Orlando, FL (Onsite)
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Appeals Specialist I
Careers Integrated Resources Inc
Orlando, FL (Onsite)
Contractor
Job Title: Appeals Specialist I
Work Location: 100% Remote (Candidates must reside in one of the following states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY* (outside greater-NYC), OH, TX, UT, WA* (outside greater-Seattle), WI)
Shift: 8:00 a.m. – 5:00 p.m. (local time zone)
Role Overview:
The Appeals Specialist I will be responsible for handling Medicare member and provider grievances, ensuring timely and compliant resolution in accordance with CMS guidelines. This position operates exclusively in a grievance-handling environment and requires strong communication and analytical skills.
Key Responsibilities:
Grievance Environment
Research and resolve Medicare grievances per CMS regulations (training provided).
Conduct comprehensive investigations into appeals, disputes, and complaints from members, providers, and external agencies.
Analyze health claims data and documentation to determine appropriate outcomes.
Request and evaluate supporting medical records, notes, and billing details.
Ensure timely and compliant responses in alignment with federal/state regulations and internal standards.
Communicate resolutions through clear written and verbal correspondence.
Draft summaries and documents that accurately represent findings and decisions.
Investigate and identify root causes of payment errors; prepare resolution responses for reconsideration requests.
Collaborate with other business partners as necessary to ensure accurate outcomes.
Minimum 2 years in a managed care operational setting (e.g., call center, appeals, or claims).
Background in health claims processing including coordination of benefits, subrogation, and eligibility criteria.
Familiarity with Medicare and Medicaid claim denials, appeals, and related regulatory requirements.
Dependability and attention to detail
Excellent grammar and written communication
Strong verbal communication and phone skills
Ability to meet production and quality standards
Proficiency in researching claims, contracts, and system configuration
Work Location: 100% Remote (Candidates must reside in one of the following states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY* (outside greater-NYC), OH, TX, UT, WA* (outside greater-Seattle), WI)
Shift: 8:00 a.m. – 5:00 p.m. (local time zone)
Role Overview:
The Appeals Specialist I will be responsible for handling Medicare member and provider grievances, ensuring timely and compliant resolution in accordance with CMS guidelines. This position operates exclusively in a grievance-handling environment and requires strong communication and analytical skills.
Key Responsibilities:
Grievance Environment
Research and resolve Medicare grievances per CMS regulations (training provided).
Conduct comprehensive investigations into appeals, disputes, and complaints from members, providers, and external agencies.
Analyze health claims data and documentation to determine appropriate outcomes.
Request and evaluate supporting medical records, notes, and billing details.
Ensure timely and compliant responses in alignment with federal/state regulations and internal standards.
Communicate resolutions through clear written and verbal correspondence.
Draft summaries and documents that accurately represent findings and decisions.
Investigate and identify root causes of payment errors; prepare resolution responses for reconsideration requests.
Collaborate with other business partners as necessary to ensure accurate outcomes.
Education: High School Diploma or equivalent
Experience:Minimum 2 years in a managed care operational setting (e.g., call center, appeals, or claims).
Background in health claims processing including coordination of benefits, subrogation, and eligibility criteria.
Familiarity with Medicare and Medicaid claim denials, appeals, and related regulatory requirements.
Dependability and attention to detail
Excellent grammar and written communication
Strong verbal communication and phone skills
Ability to meet production and quality standards
Proficiency in researching claims, contracts, and system configuration
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